Tradition

In “Fiddler on the Roof” Tevye struggles with the blurring of traditional roles and choices for his children. Why must we keep doing what was done by previous generations? Tevye answers in song ,”Tradition!”

This past weekend I participated in a ceremony that is hundreds of years old – commencement. The end of a period of academic study, it is seen as not only the conclusion of one phase in the student’s life, but the beginning of another. So why would a 54 year old surgeon fly back to Boston from Los Angeles, to dress in medieval academic garb, and stand in the sun with 4000 others for several hours.

Tradition!

The commencement ceremonies at Harvard Yard predate the founding of this country. And from the initial class of 9, certain consistencies have been passed from generation to generation. Bagpipers escort the classes through the various gates surrounding the central yard, undergraduates congregate to the left, graduate students to the right, with the oldest schools situated closer to the stage. The President and Fellows arrive, wearing the traditional garb of their home doctoral institutions. To begin the ceremony, the Sherriff of Middlesex County, as he has for over 3 centuries, approaches the lectern and bangs a silver tipped cane three times, calling the meeting to order. Three speeches are given, from memory, by two undergraduates and a graduate student. The first was in perfect Latin (a variation of “Wheel of Fortune.”) With specific scripting, each school is asked to rise, and the President bestows the degree en masse. Symbols are waved by each class – gavels for the lawyers, angel wings for theology, stethoscopes for the med school. We in Public Health were given plastic fruit.

The awarding of the honorary degrees was a bit more light hearted, the provost introducing each honoree as if it were a game show. The high point was when Placido Dominigo, after receiving his degree, sang the citation to Justice Ruth Ginsberg, herself an avid opera fan.
The Sherriff, still regal in a top hat and tails, again banged three times, and dismissed the meeting.

On the streets of Cambridge, several of my classmates and I were stopped by a group of Japanese tourists, who wanted their pictures taken with us in full dress. I must admit it was a little strange.

In the afternoon, we did the walk across the stage to receive our copy of the Declaration of Human rights. All of the School of Public Health was present, and after another set of addresses, the 480 names were dispensed with fairly efficiently.

In the crowds afterwards, my classmates all dispersed to meet family and friends. No real chance for a formal goodbye. I turned in my gown (kept the tassel, I guess for the rearview mirror), and picked up my diploma. More than 25 years since I last graduated from a formal program. The same sense of accomplishment, perhaps a bit more pragmatism, and a bit less uncertainty. And I wondered what to do next.

When my middle child, Adam, graduated from Hamphshire College, there were no caps and gowns, the diplomas were a circle and you were identified by the year that you entered, not graduated, signifying the beginning of lifelong learning. A tradition reflecting the nature and values of this innovative institution. At Wesleyan, my oldest son, Ben, walked with his classmates down the hill between rows of faculty who formed the entrance to the field and applauded the graduates. I will feel intense emotions next year when Rachel graduates from Hopkins.

Traditions may not make great sense in a modern world. In reality, our transcripts are all electronic, and the diploma could be sent as a pdf file. Yet we as humans do things that aren’t always rational, but give us a sense of continuity. Perhaps it is our own way to assure a degree of immortality – continue the traditions of those who raised us and are no longer here, hope that our children and grandchildren will remember us through traditions after we are gone.


It’s been a while since my last post – finishing school and some new work projects have kept me busy. But I look forward to sharing with you more perspectives on Haiti and Hospital Sacre Coeur – Rachel and I will be travel there in mid June for a week.

Now there’s a tradition I hope will endure…

A World View

Last Sunday evening, I was returning from dinner with several of my classmates in Boston. Entering the hotel, we saw the television with a somber Wolf Blitzer building up to President Obama’s remark about “an issue of national security.” As we sat in the lobby, I looked around and realized that half the people I was with were from other countries. How would they react? Is this as big a deal to them as it is to Americans?

Earlier that weekend, we presented our year long practicum projects, a extensive planning and execution program. Those that have been following this blog know I worked on our ambitious inventory control project for Hospital Sacre Coeur. As I detailed what we have and haven’t been able to complete, I found myself discussing civil unrest, cholera outbreaks, and electricity that goes out twice a day during the switch from the generator to inverters. I also showed pictures of the volunteer electricians from the San Francisco bay area, Ed Constantine and his airplane, and the Haitian workers, digging out stumps and pouring concrete by hand to cultivate the sprung building. It was a remarkable examination of what can be done when committed to a cause.

At the same time, I listened to presentations as diverse as improving the experience of complex cardiac surgery patients in the Netherlands, to the challenges of attracting a new chief to a struggling academic department, and how to get specialists to cover an emergency room at night, when the patients had no insurance. Other international projects began an ophthalmology residency in Cambodia, examined the cultures and motivations of the staff in an inner city federally funded health care center, or presented the business plan for merging several multimillion dollar cardiology practices to maintain viability given massive cuts in reimbursement. The key theme was that by understanding what motivates people, aligning the incentives to meet those motivations, and realizing that all of life is shades of grey, problems can be addressed and the human condition improved.

What does this have to do with the killing of Osama bin Laden? My colleagues from other countries were happy for America that it had achieved a goal and found some degree of justice. But they were also saddened at the amount of resources and lives that we expended in fighting these wars. A recent NPR broadcast discussed the “the economic death of a thousand cuts” as one of the methods used by terrorists. There is no question that every country must defend its people, and in societies, certain segments need to take on the role of policeman. We in America have chosen that role, and also have had it has been thrust upon us.




I’ve definitely developed a broader view of the world and human needs over these past two years, both by listening to others perspectives, and experiencing it myself. I don’t have even a small number of the answers, but based on what I’ve seen from Cohort 11 of the Heath Care Management Program at the Harvard School of Public Health, I have great hope that the answers are out there, and we have talented, commited people willing to find them.

Passover in the Land of Stars

It’s about 3 miles from my office at Cedars-Sinai to where I’m currently living in Beverlywood. I’ve been walking a fair amount lately, and the route is quite interesting. We border Beverly Hills and West Hollywood. As I walk south, I cross very familiar streets- Wilshire Boulevard, Rodeo Drive, Beverly Boulevard. The Four Seasons Hotel, with a statue of Marilyn Monroe, is on Doheny and I always check to see if the paparazzi are out. As I head through “The Flats” the homes are classic California Spanish, on very small lots. Garages are almost always converted to living space, so upscale cars are parked outside, along the street or on short driveways. I ‘m wearing my suit, and nod to the occasional dogwalkers or retirees out for a stroll in their jogging suits.

Crossing Olympic, the scenery changes – there are more apartments, and small businesses. The lawns, though neat, are not as groomed. Turning on Pico, I now see more men in suits and women pushing baby strollers. It is the first night of Passover and the observant community near my home are heading for Sedars. A similar scene occurs every Saturday, as families stroll to services, stopping to talk and coo over babies. The youngsters later play ball in their driveways, wearing yarmulkes that match their tennis shoes.

Last year, I celebrated Passover in a poor country, founded by slaves, one of the few Jews within 50 miles. Today I am immersed in my historic community and culture. And the economy responds to demands. It is easy to keep Kosher and live within walking distance of Temples and other activities. There was even a brisk business of portable car cleaners, who vacuumed every last bit of breadcrumbs from your interior.


We had a small Sedar. Ben and Janine invited some Wesleyan friends, and the realtor that found us the rental joined us. (Her first husband was Jewish.) We did have some Mogen David wine, but immediately deferred to a Napa Cabernet. The story of the Exodus was retold, we had some laughs, and a great meal.

Later, I was walking Chester through the neighborhood; I could glance into homes, and see families still surrounding the dining room table, with multiple generations. In some cases, the doors were open and one could hear the conversation and singing. I felt a strange sense of both connection and discomfort.

Returning home, the others were gathered around the fireplace and I sat and listened for awhile. It was the optimistic, energetic thoughts of the next generation – I remember being in their place. And I remember a promise I made to myself.

There was some Matzah left over. I found the peanut butter and cut up a scallion. The 5 star rum was still in the freezer, and I squeezed some orange juice. On the back patio it was dark, and many of the stars were obscured by the haze and lights of the city. I could still hear the crickets, as I had in Milot. In the distance, the sounds of I 10 and planes on approach to LAX. What an amazing contrast and at the same time confluence. Whether you a Christian, Jewish, Catholic, Muslim, or an agnostic, you are part of something greater. Looking both within and out, we experience the world through our communities. They may change as we gain more insight, and align with those with whom we resonate.

Two years ago, in Hartford, I never thought I’d spend Passover in Haiti, one year ago, in Milot, Los Angeles was nowhere on the radar, and next year?

As Sedar concludes we say L’shana habaha b’Yerushaliyim – next year in Jerusalem. But in reality – it is not a physical place – it is the reminder that we must all continue to evolve and strive for our goals, whether they be personal professional or spiritual.

And so for each of you, may you find your own Jerusalem and have the drive, support, and good fortune to reach it.

Forward to the Past?

“He who knows syphilis, knows medicine”
-Sir William Osler, First Physician-in-Chief, Johns Hopkins Hospital

It’s been an interesting week for me in my various healthcare roles. I’m currently en route to Dallas, where I will participate in a summit on using a balanced scorecard to assess and compare individual physician performance, as a preface to public reporting. The long awaited Accountable Care Organization guidelines (429 pages) were released. At the same time, Hospital Sacre Coeur and CRUDEM are working to expand interventional cardiology services to include treatment of rheumatic heart disease. Finally, I have been involved in the recruitment of an individual involved in public health. When I asked how he would measure his success, he said that one key would be the elimination of syphilis in urban areas. (and this was in the US!)

It is easy to forget, that a century ago infectious diseases and their complications were the leading cause of death and disability. Syphillis caused more than genital lesions. The spirochetes would house in the walls of the aorta, especially exiting the heart, causing weakening, dilation, and death from rupture. In other forms, it manifest as neurosyphilis , causing confusion and delusions. Some have hypothesized the former Ugandan dictator Idi Amin’s bazaar behavior was due to neurosyphillis. One of our most shameful legacies in human subjects research was the Tuskegee experiment, where minority individuals with syphilis were not treated to follow the natural history of the disease. The concept of “bad blood” reflected the explanation given for the progressive illness. Many died of the one of the multitudes of complications.

Rheumatic heart disease is the sequelae of untreated streptococcal infections of childhood, such as recurrent tonsillitis, and strep throat. Although these are easily treated now with antibiotics, this is not the case in Haiti. The antibodies to strep can form vegetations on the heart valves, especially the mitral valve between the left atrium and left ventricle. This cause stiffening and narrowing of the valve, reducing blood flow from the lungs to the rest of the body. Patient develp a classic murmur, then progressive pulmonary edema and eventually heart failure. This is especially tragic in Haiti, when young woman die during pregnancy as their hearts cannot increase output in responses to the demands of pregnancy. Medications can only do so much. Autopsies confirm this is a mechanical problem. As surgeons, we seek mechanical solutions. How can you mend a broken heart? (Sorry Barry Gibb)


Before the development of cardiopulmonary bypass in the 1950’s and 60’s, and cardiac procedures were done with the heat still beating. Normal output from the heart is about a gallon a minute, and the mitral valve was accessible only by opening the heart muscle. As early as 1925, Souttar reported an elegant, if somewhat simple solution. There is a small outpouching from the left atrium, the appendage. If a purse string suture is placed around the appendage at its base, the tip can be cut off and a finger placed into the left atrium, until it reached the mitral valve. The opening was restored by fracturing the vegetations with the finger, hopefully not completely destroying the valve. The finger was removed and the purse string tied down, closing the hole. Subsequently, devices for mitral commisurotomy were developed to replace the finger and provide a more controlled dilation. With the sophistication of cardiopulmonary bypass, we now arrest the heart, and physically replace the valve. But what about countries like Haiti, where there just isn’t the infrastructure yet to carry a patient safely through cardiac surgery, let alone long term followup?

It may be time to look back to guide how we go forward.

Several years ago, the cardiac surgery team at my previous place, the Miriam, travelled to Africa and did open mitral commisurotomies without bypass, as I described. The patients overall did well. Since then, intervention techniques that can access the heart via an artery may be able to obviate the need for a surgical incision. Mitral commisurotomy can now be accomplished with a specialized balloon, under fluoroscopic guidance, in a cath lab environment.



We are examining how to accomplish this in Milot. We do have some fluoroscopy equipment and improving ICU capabilities. Teams of cardiologists can come for a week at a time to do the actual procedure, but we must involve our Haitian colleagues in the preoperative identification and postoperative care of these patients, eventually training them in cath procedures. This starts with using echocardiograms to assess degree of stenosis and heart function. When I was in Milot in September, Dr William Battles, an echocardiographer was training the first group. As he was doing it, I watched. He smiled and said, “so simple a surgeon could do it.” (Later that night, a man came in with multiple deep facial and arm lacerations from a machete. Bill was the only other doc around. I took him to the OR, reassuring him that “even an echocardiologist can do this…”, but that’s for another blog.)

While reflecting on the high yield from treating basic infectious disease and public health problems I am concommitantly overwhelmed with the amount of data we collect and policies we propagate trying to make American medicine affordable, effective, and appropriate. We need to help physicians understand how they practice and how we can learn from each other to optimize care. We can legislate to align incentives, with both a carrot and a stick. I’m still not sure how it will drive behavior.

But I do know that I never again want to watch a 23 year old Haitian girl die of progressive heart failure from untreatable rheumatic heart disease. I look forward to when we can bring the balloons to Milot, and if not, there’s always your index finger and a 2-0 Prolene suture for the left atrium.

…and I’m not sure how that will fit into the ACO paradigm.

Evidence Based Decisions and the Art of Medicine

“The evidence clearly shows……”

How often have we heard that argument made, trying to influence our choices or behaviors. Experts provide data that support their point of view, often in the face of conflicting information. We would like to believe that we always make rational decisions based on facts. But human nature proves otherwise. We will base our most recent decision on how the last situation played out. Negative outcomes, even if infrequent, have a greater influence on future behavior than their true weight. And as clinicians we are often told, “Judgment comes from experience, and experience comes from poor judgment.”

So it has been very interesting for me in my new position to work with clinicians and systems on best practices for various patient conditions. Unlike the “hard” sciences like physics, mathematics, and chemistry, soft sciences like medicine and pathophysiology have shades of grey. Even the best designed studies are inherently ambiguous, and the literature tends to further this bias by publishing studies where a beneficial difference is found, as opposed to equivalence or detriment. How do we sort through the data and try to come to a rational conclusion?

By analyzing how to analyze data.



Health service researchers have developed an elaborate grid that attempts to balance the potential benefit of an intervention with the strength of the data supporting that intervention. These decisions subsequently form the basis for clinical guidelines, and in many cases, whether the service will be paid for. The strongest recommendations, IA , are the most stringent , and should be generally accepted. III A findings strogly support more harm than good. You can see where the ambiguity comes in. A IC may well be good, but there’s not strong randomized data. By the same token, a IIIC recommendation not to do something is less of an indictment than a IIIA. As a surgeon, who has spent the last 30 years trying to do the best for my patients, often with limited available data, this is clearly a shift in thinking. We were trained to listen and examine the patient and then determine if they were sick and needed an operation. Subsequently, the specifics of the diagnosis would often be revealed in the operating room.

So why is this new paradigm important? Increasingly, with limited resources, we may be steered to provide or defer therapies based on into what evidence category the question falls. Could “Watson,” when he’s not winning at Jeopardy, calmly crunch all the potential permutations and risks to come to a definitive plan? I suppose he could, but I hope we don’t come to that alone.

When I was still a medical student, Arnie Rosenbaum, an internist in my hometown of Canton, took me on rounds. In each patient’s room, he would sit at the bedside, and take their blood pressure, while gently feeling their pulse. Afterwards, I asked why he would do this when the data were already on the clipboard. “Because I always touch my patients and look them in the eye. It really tells me how they’re doing. And when the time comes for me to be a patient, I hope my doctor makes the same human connection.”

My n=1 in this nonrandomized study of internists in Canton Ohio in 1979. But based on my experiences since then, that’s Level IA data in my eyes.

Making the Tough Choices

Two massive earthquakes – 2 very different patterns of death and destruction
I knew this one would be different than a year ago, when people asked- “So are you going to Japan to help?” The answer was quickly “No, they really don’t need me.” By the same token, my colleague Glenn Braunstein, Chair of Medicine at Cedars and a superb endocrinologist, has been bombarded with requests for interviews and advice regarding potassium iodide to reduce the risks of radiation exposure.

The drama unfolding in Japan is no less riveting than what happened in Haiti, but for different reasons. The patterns of death and injury were not from collapsing buildings or lack of infrastructure – it was rapid and massive related to the Tsunami. The Japanese government is well organized to deal with earthquakes and has teams and supplies available. Building codes are strict. But no one could anticipate the difficult decisions related to the Fukushima Dai-ichi nuclear plant. The risks of additional injury and death are significant, and resources are being poured into the area to minimize harm. Although rescue and recovery operations continue, they seem to have taken a lower priority to preventing additional catastrophes.

What we see in action in Japan is similar to other disaster scenarios - the use of triage. Triage actually originated during the Napoleonic wars with Dominque Larrey, a French battlefield surgeon. He designed some of the first ambulances used on the battlefield, would treat enemy soldiers along with his own countrymen. He recognized that you needed to make a best guess at how to get the most good for the most patients, which may mean not treating those who were likely to die, or would consume disproportionate resources. It is a form of utilitarianism where one tries to maximize benefit for the greatest number, even if the decisions may not be best for an individual.

We saw triage in Haiti, when we were truly resource constrained. Patients that would have survived in the States, were allowed to die comfortably. Others might have quality of life worse than death. Throughout my surgical career, I have been faced with the decisions – they don’t get easier, but after some time, you gain perspective.

Like it or not, we will be performing some type of high level triage if health care in America is to survive. For now, we seem to have unlimited resources, but just because we CAN do something, doesn’t me we SHOULD. Resources spent in futile care, are resources that could immunize a child, provide safe water, or help educate a generation. This isn’t about Death Panels - it’s about having an honest dialogue about where priorities are placed to stabilize the present and build to the future.

There may be a few setbacks along the way for the Japanese. But a year from now, unlike Haiti, they will be back on their feet and stronger with the knowledge of what they learned.

Freedom of Choice

“All around the world, it’s so easy to see. People everywhere just want to be free..."




I am currently over Ontario enroute from Boston. I look down on the landscape of farms, interspersed towns, and the city of Toronto in the distance. It is a route I have traveled often, especially when I was based in Rochester. I fondly remember trips to Canada, and the palpable sense of a difference in tolerance and priorities as I crossed the border. The newspaper in my seat pocket recounts the unrest in the Middle East, and concerns that oil prices rising above $100/ barrel will inhibit Americas own economic recovery. Gas is $4 a gallon in LA, yet, I don’t see any fewer cars on the road.(Driving, in California, is freedom.) There are protests in countries that we normally don’t recognize as foci of discontent – Tunisia and Liberia for example. We wonder what drives people to risk their lives to overthrow a government, when they know that whatever follows could be as equally oppressive. In a commentary, WSJ columnist Michael Novak notes that the desire for liberty is universal and rooted in basic Judeo – Christian beliefs. We talk of free choice, and consequences – whether to eat the apple, whether to accept a deity or idols, how we choose to do business with one another. What I am realizing is that even the replacement of one corrupt government with another, is an expression of the peoples freedom to choose their destiny. Whether extremists can recognize this basic human value or will continue to oppress women and the less well to do remains to be seen.

I am returning from one of my final weekends in the healthcare management course at the Harvard School of Public Health. As we looked at payment systems, it was not surprising that the US high cost for moderate quality paradigm was again examined. Classmates from Israel, the Netherlands, Australia, Canada, and Dubai discussed their own countries; how resources for health care were collected, how they were pooled, and how they were distributed. We fervently debated market pressures, the malpractice environment, and free market competition. Trying to place any of their systems in the US, despite the fact that there was “more bang for the buck,” seemed untenable.

Then we reframed the discussion, and the light went on – it’s all about choice.
Americans are fiercely independent, and pride themselves on being able to guide their own destitny. There is some sense of social responsibility for the less fortunate, but the disparities between the haves and the have nots are extreme. Americans want free choice in whether they drink or smoke, or want to be able to take a medication in lieu of exercise - and they don’t like to wait. This impatient spirit helped us accomplish great things in the past, but may be blinding us to the realities of the present.

There is no question that the American health system is expensive and inefficient. It is focused on technological repair of disease as opposed to a societal understanding of health, responsibility, and support. We realized that by dealing with the economic disparities, many of the health disparities would be ameliorated.

“My God,” you say, “He’s moved to California and is eating too much granola.”

Not so. I believe in technological advances in medicine to reduce suffering. Surgery is one of the most cost effective ways to return someone to health and being again productive. My classmate, who is Chief of Cardiac Surgery at the Hague, does 8-12 case /week – as part of a well organized integrated system in a relatively small country. It has nothing to do with socialized medicine.



Looking at the other countries we discussed, the populations are fairly homogeneous, resources can be concentrated near population centers, and from the time you are a child, there is an understanding that you may need to wait to have your needs met, but they will be. America is vast, we have huge variances in population density and medical resources. There is a safety net available, in public hospitals and emergency rooms but it is not the best way to provide continuity of care.
So how do we tie the unrest in many of the middle eastern countries to public health. And how do we help Americans realize that there must be a change in their perceptions and responsibilities?

It is by understanding that as humans, we want some control of our destiny. Depending on how well our basic needs are met,(remember Maslow’s pyramid?) we are willing to trade some free choice. But when oppression is coupled with poverty, an uprising is inevitable. In a similar manner, American health care is impoverished in the midst of plenty, and the shift must come at the center – with the patient.

Being proactive in your health, making good choices, and partnering with your provider isn’t limiting – it’s the ultimate source of freedom and self actualization.